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Reference
Appendix and Legal Notices
the cost of preparing the summary or explanation. Your
right of access is limited. For example, you do not have
the right of access to psychotherapy notes, to information
used in judicial or administrative proceedings or to infor-
mation that is subject to the federal Privacy Act or under a
promise of confidentiality. The Plan may deny you access
to your PHI in the Plan’s records. You may, under some
circumstances, request a review of that denial. If the Plan
or its business associates maintain electronic records
of your PHI, you may request an electronic copy of your
PHI. You may also request that your electronic records be
sent to a third party.
You have a right to amend PHI about you that is
maintained by the Plan.
Your request must be in writing and you must give a
reason for the request. Your right to amend is limited.
For example, you can only amend information that is
available to you under your right of access. The Plan may
deny your request if the information was not created by
the Plan and the creator of the information is available to
respond to your request. The Plan may deny your request
if the information is accurate and complete.
You have a right to receive an accounting of some (but
not all) disclosures made by the Plan.
You may request an accounting of disclosures of your
PHI made within the six-year period just before the
date of your request. Your request must be in writing.
The accounting will not include disclosures the Plan
is permitted to make for treatment, payment and
health-care operations, or those made with your authori-
zation. The accounting will not include disclosures made
to you or close family members involved in your care. The
accounting will not include disclosures made for purposes
of national security, incidental to otherwise permitted or
required disclosures, as part of a limited data set or to
correctional institutions or law enforcement officials. Your
right to an accounting may be suspended in the event of
certain government activities. If you request more than
one accounting within a 12-month period, the Plan may
charge you a cost-based fee for the additional requests.
You have a right to receive a paper copy of this notice.
If you have agreed to receive this notice by email, you
also have a right to receive a paper copy upon request.
You have a right to receive notification of a breach of your PHI.
You will be notified if your unsecured PHI is acquired,
accessed, used or disclosed in a manner that is not
permitted under HIPAA and the security or privacy of your
PHI is compromised.
Complaints
You may complain to the Plan or to the Secretary of the
U.S. Department of Health and Human Services if you
believe your privacy rights have been violated. Complaints
to the Plan should be made using the form provided by
the Benefits Manager. If your complaint is with an insurer
or HMO, you may file a complaint with the individual
named in the insurer’s or HMO’s notice of privacy
practices to receive complaints. Retaliation against a
person who files a complaint is prohibited.
To file a complaint with the Secretary of the U.S.
Department of Health and Human Services, you must
submit your complaint in writing, either on paper or
electronically, within 180 days of the date you knew or
should have known that the violation occurred.
You must state who you are complaining about and the
acts or omissions you believe are violations of HIPAA’s
privacy rules. Complaints sent to the Secretary of the
U.S. Department of Health and Human Services must be
addressed to the regional office of the U.S. Department
of Health and Human Services’ Office of Civil Rights for
the state in which the alleged violation occurred. For
information on the regional office at which you must file
your complaint, and the address of that regional office,
go to the Office of Civil Rights’ web site at
